Provider Demographics
NPI:1083618805
Name:SEWELL, GLEN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:THOMAS
Last Name:SEWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 STARDUST ST
Mailing Address - Street 2:STE D
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4264
Mailing Address - Country:US
Mailing Address - Phone:775-746-3400
Mailing Address - Fax:775-746-3411
Practice Address - Street 1:1350 STARDUST ST
Practice Address - Street 2:STE D
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4264
Practice Address - Country:US
Practice Address - Phone:775-746-3400
Practice Address - Fax:775-746-3411
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3580207ZP0102X
CAG38179207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVXPY068120OtherMEDICAL
NVA47387Medicare UPIN
NVV9L0008062Medicare ID - Type Unspecified